Developmental Milestones
Nurses know the posterior fontanelle typically close in infants at the age of
2-3 months.
Rationale: The posterior fontanelle closes earlier than the anterior one, which closes by 18-24 months. This is a key developmental milestone for cranial growth assessment.
This is the hallmark sign of coarctation of the aorta in children...
High blood pressure in the upper extremities and weak or absent pulses in the lower extremities.
Rationale: This congenital condition narrows the aorta, affecting blood flow.
What type of car seat is recommended for a 1-year-old weighing 20 pounds?
A rear-facing car seat.
Rationale: Rear-facing seats provide optimal protection for infants and toddlers.
This medication is given to maintain ductal patency in neonates with congenital heart defects...
Prostaglandin E.
Rationale: Prostaglandins keep the ductus arteriosus open, ensuring adequate oxygenation.
My priority action as a nurse when a child presents with continuous swallowing after a tonsillectomy
Notify the provider immediately, as this may indicate hemorrhage.
Rationale: Early detection of bleeding prevents complications.
Which gross motor skill is typically achieved by a 9-month-old infant?
Pulling to stand.
Rationale: This is a milestone indicating strengthening of leg muscles and preparation for walking.
These four defects comprise the Tetralogy of Fallot...
Pulmonary stenosis, ventricular septal defect, right ventricular hypertrophy, and an overriding aorta.
Rationale: Understanding the anatomy helps nurses anticipate complications such as cyanosis or "tet spells."
I will educate parents on these two ways to reduce the risk of SIDS in infants
Place the infant on their back to sleep and keep the sleep area free of soft bedding and toys.
Rationale: These are evidence-based strategies for SIDS prevention.
Oral iron is best administered with _______, while avoiding _____ to maximize absorption.
On an empty stomach with vitamin C, avoiding calcium.
Rationale: Vitamin C enhances absorption, while calcium inhibits it.
A toddler says "no" during routine care, a nurse says______
Offer limited choices to avoid power struggles (e.g., "Do you want to hold the bandage or the tape?").
Rationale: This approach reduces negativism and promotes cooperation.
A toddler is in the "autonomy vs. shame and doubt" stage according to Erikson. To support autonomy a nurse will
Allow the child to choose between two options (i.e. picking between a red or blue cup; picking a pink or blue bandaid, etc...)
Rationale: Limited choices promote independence while ensuring compliance.
As a nurse, the intervention I will implement for a child with Kawasaki disease is...
Monitor for coronary artery aneurysms and administer IVIG.
Rationale: Kawasaki disease can cause life-threatening cardiac complications if not treated promptly.
Parents will manage an avulsed tooth in a school-age child by...
Keeping the tooth moist in milk or saline and seeking immediate dental care.
Rationale: This preserves the tooth and increases the chances of successful re-implantation.
When administering digoxin to a pediatric patient, I must consider
Monitoring the apical pulse for one full minute; and hold the dose if bradycardia is present.
Rationale: Digoxin slows the heart rate, and bradycardia may indicate toxicity.
This nursing intervention is critical during a pediatric seizure
Turn the child onto their side to maintain airway patency and prevent aspiration.
Rationale: This position ensures safety during seizure activity.
Identify a cognitive milestone that distinguishes toddlers from infants in Piaget's theory.
The development of object permanence.
Rationale: Object permanence is the understanding that objects exist even when out of sight and is typically developed by the end of the sensorimotor stage (around 2 years).
Describe the pathophysiology of cystic fibrosis.
Cystic fibrosis is a genetic disorder affecting chloride transport, leading to thick mucus production in the lungs and digestive tract.
Rationale: This understanding guides respiratory and nutritional care.
These precautions are necessary for a child admitted with suspected pertussis...
Droplet precautions.
Rationale: Pertussis spreads via respiratory droplets; isolation prevents transmission.
The side effects of corticosteroid use in children
Growth delays, immunosuppression, and hyperglycemia.
Rationale: These effects require monitoring during prolonged therapy.
A nurse provides atraumatic care during an IV insertion, when he or she
Applies EMLA cream (eutectic mixture of local anesthetics) one hour before the procedure.
Rationale: Topical anesthetics minimize pain and distress.
Magical thinking is prevalent in preschool-aged children because
Preschoolers are in the preoperational stage of cognitive development, where symbolic thought and egocentric perspectives dominate.
Rationale: Magical thinking allows them to interpret the world in ways that fit their limited understanding.
Differentiate between Hirschsprung disease and intussusception in terms of symptoms.
Hirschsprung disease presents with chronic constipation and abdominal distention, while intussusception typically shows intermittent abdominal pain and currant jelly stools.
Rationale: Clear symptom differentiation is critical for accurate diagnosis and timely surgical intervention.
This intervention is critical in managing severe dehydration in a pediatric patient...
Administer IV fluids and monitor urine output.
Rationale: These measures restore hydration and assess kidney function.
This medication is used as a first-line treatment for febrile seizures
Antipyretics like acetaminophen.
Rationale: Treating the underlying fever helps prevent recurrence.
Nursing considerations post-cardiac catheterization in a child, that I will implement
Monitor for bleeding, maintain leg immobility, and assess for signs of infection.
Rationale: These interventions ensure recovery and prevent complications.